Doctoral thesis -abstract- study of... · Doctoral thesis -abstract-Academic advisor: Professor Dr. FLORICA POPESCU, PhD PhD student: Dr. Camelia Daniela GUTA CRAIOVA 2013. UNIVERSITY

UNIVERSITY OF MEDICINE AND PHARMACY OF CRAIOVA

FACULTY OF MEDICINE

Doctoral thesis

-abstract-

Academic advisor:

Professor Dr. FLORICA POPESCU, PhD

PhD student:

Dr. Camelia Daniela GUTA

CRAIOVA

2013

UNIVERSITY OF MEDICINE AND PHARMACY OF CRAIOVA

FACULTY OF MEDICINE

1

Microbiological study of antepartum

and postpartum vaginal flora.

Clinical and laboratory research and

therapeutical particularities.

Keywords: S. aureus, E. coli, bacterial vaginosis, pregnant women,

postpartum women.

Academic advisor:

Professor Dr. FLORICA POPESCU, PhD

PhD student:

Dr. Camelia Daniela Guta

CRAIOVA

2013

2

CONTENTS

CONTENTS ................................................................................................................................................. 2

LITERATURE ............................................................................................................................................. 3

NORMAL VAGINAL FLORA .................................................................................................................................... 3

OWN CONTRIBUTIONS ............................................................................................................................ 4

PURPOSE OF THE STUDY ....................................................................................................................................... 4

OBJECTIVES OF THE RESEARCH ............................................................................................................................ 4

THE DESIGN OF THE STUDY .................................................................................................................................. 5

RESULTS AND DISCUSSION ..................................................................................................................... 5

DISTRIBUTION OF CASES IN PREGNANT AND POSTPARTUM WOMEN ................................................. 6

COMPLICATIONS OF INFECTIONS WITH S. AUREUS TO PREGNANT WOMEN OF THIRD TRIMESTER ............. 6

COMPLICATIONS OF VAGINAL INFECTIONS WITH E. COLI TO PREGNANT WOMEN OF THIRD TRIMESTER .... 7

COMPLICATIONS OF GENITAL INFECTIONS WITH S. AUREUS TO POSTPARTUM WOMEN ............................ 7

COMPLICATIONS OF GENITAL INFECTIONS WITH E. COLI TO POSTPARTUM WOMEN ................................. 7

ANALYSIS OF SENSITIVITY TO ANTIBIOTICS AND CHEMOTHERAPY AGENTS OF S. AUREUS AND E. COLI ...... 8

Sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated from pregnant women with a

history of staphylococcal infections (subgroup A1) .......................................................................................8

Sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated from pregnant women without

a history of staphylococcal infections (subgroup A2)………………………………………………… .........8

Sensitivity to antibiotics and chemotherapeutic agents of E. coli isolated from pregnant women with a

history of E. coli infections (subgroup B1) - Figure 3. ..................................................................................9

Sensitivity to antibiotics and chemotherapeutic agents of E. coli isolated from pregnant women without a

history of E.coli infections (subgroup B2)…………………………………………………. ..........................9

Sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated from postpartum women with a

history of staphylococcal infections (subgroup C1) .................................................................................... 10

Sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated from postpartum women

without a history of staphylococcal infections (subgroup C2)……………….. ........................................... 11

Sensitivity to antibiotics and chemotherapeutic agents of E. coli isolated from postpartum women with a

history of E.coli infections (subgroup D1) .................................................................................................... 11

Sensitivity to antibiotics and chemotherapeutic agents of E. coli isolated from postpartum women without

a history of E. coli infections (subgroup D2) ............................................................................................... 12

GENERAL CONCLUSIONS ...................................................................................................................... 13

SELECTIVE BIBLIOGRAPHY .................................................................................................................... 16

3

LITERATURE

High prevalence of gynecological infections worldwide requires that every patient with

gynecological symptoms should be carefully investigated.

Genital infections with Escherichia coli or Staphylococcus aureus are more common in

nasal carriers of S. aureus or occur in case of prolonged or repeated hospitalizations of

patients with multiple risk factors.

In obstetrical or gynecological infectious pathology, Escherichia coli can function as a

monoetiological pathogen causing urinary infections or chorioamnionitis or can be isolated in

polymicrobial infections (e.g. septic abortion, postpartum endometritis or wound infection).

Both monoetiological and polymicrobial infections can cause septicemia.

Coagulase-positive staphylococci, important constituents of the microbiological flora of

the skin, may play an important role in wound infection. Their ability to replicate in aerobic

and anaerobic conditions and their ability to synthesize bacteriocins and bacteriocin-like

substances increases the recognition of this organism as a cause of wound infections, although

the anaerobes which are concurrently involved often escape recognition. Staphylococcus

aureus functions as a copathogen in the progressive gangrene of soft tissues.1

Staphylococcus aureus is the most prevalent vaginal pathogen and remains one of the

germs the most involved in infection, an incidence which is steadily increasing. The

colonization of the vaginal mucous membrane with this germ can predispose to toxicoseptic

shock.2

NORMAL VAGINAL FLORA

Normal flora of the lower female genital tract is complex but very little known in detail.

Normal vaginal flora contains a wide range of bacteria but it mainly consists of lactobacilli

(90-95%) and other bacterial species found in extremely small percentages.

Most women present at vaginal level a single dominant species and they are colonized by a

single species of lactobacilli. Lactobacillus crispatum and Lactobacillus jensenii are the most

commonly found in Caucasians. Lactobacilli maintain the normal vaginal ecosystem, inhibiting

the growth, adhesion and expansion of potential pathogens.3

Normal microbial flora of the vagina is an important factor in the antiinfectious defense

of this ecosystem.

The resident flora include those micro-organisms well adapted to the conditions of the

vaginal ecosystem, fairly constant in its component species and characteristic to it, and it is

found inside the vagina from puberty until menopause.

4

The composition of the resident flora is represented by those microorganisms

phylogenetically selected and adapted to the conditions offered by epithelium lining of the

vaginal mucous.

Quite often there are established symbiotic relationships between the host and her

resident flora. Due to the ideal adaptations to the development on the vaginal mucous

membrane, the resident flora prevent the populating of vagina with other more aggressive

species. Thus, its main action is antipatogenic.8, 4

Floating flora is represented by those bacterial species unadapted or less adapted to the

vaginal ecosystem, so it comes to species with temporary variable persistence. Under normal

health conditions, these micro-organisms are efficiently countered, their presence on the

surface of the epithelium of the vaginal mucous being nonmanifest.5

Normal vaginal flora is dynamic, presenting numerous fluctuations throughout a

woman's life, under the influence of hormones, sexual activity and associated diseases.5

Numerous studies have been carried out on the vaginal flora of pregnant women and it has

been demonstrated that it is represented by Gram positive cocci, Gram positive bacilli and Gram

negative bacilli.6

Purpose of the study

OWN CONTRIBUTIONS

Genital infections during perinatal period are a relatively common cause of morbidity,

occurring in approximately one third of pregnant women. Late presentation to the doctor

increases the risk of maternal-infant morbidity on the one hand and of premature birth on the

other hand.

Inappropriate use of antibiotics has resulted in the occurrence of attenuated clinical

forms of genital infections which chronicized, infections with germs with multiresistance to

usual antibiotics.

The aim of our study is to analyze the clinical and paraclinical and therapeutic

peculiarities in genital infections occurring in antepartum and postpartum, caused by

Staphylococcus aureus and Escherichia coli, by microbiological study of the vaginal flora, in

order to better understand the patterns of colonization and to prevent infection by the two

germs during the peripartum. In addition, the study will also focus on optimizing and

improving the treatment of genital infections caused by the two germs.

OBJECTIVES of the RESEARCH

The research objectives are:

5

o Microbiological study of vaginal flora in antepartum and postpartum genital

infections;

o Study of sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated

in genital infections occurring perinatally;

o Study of sensitivity to antibiotics and chemotherapeutic agents of E. coli isolated in

genital infections occurred antepartum and/postpartum;

o Evaluation of clinical-paraclinical and therapeutic peculiarities for S. aureus and E.

coli.

Design of the study

RESULTS and DISCUSSION

From the 686 samples taken from pregnant and postpartum women during the period

1 January 2007 - 31 December 2010, along with the strains of S. aureus (153 cases) and E.

coli (190 cases), we isolated and identified strains of Streptococcus gr. B, Klebsiella spp.,

Enterobacter spp., Citrobacter spp., Pseudomonas aeruginosa, Proteus spp., anaerobic

germs, Enterococcus and Candida spp., met with a much lower frequency (Figure 1).

6

200

180

160

140

120

100

80

60

40

20

0

Figure 1. Graphical representation of bacterial strains isolated from vaginal secretions and

lochia.

Distribution of cases in pregnant and postpartum women

The 343 cases of genital infections with S. aureus and E. coli were classified as follows:

172 (50.15%) of cases in pregnant women in the third trimester and 171 (49.85%) cases in

postpartum women within the first 3 days postpartum. The average age across the entire study

group was 30.28 ± 7.68 years, and within the 20-35 years group occurred the most cases of

genital infections (229 patients, 66.76%).

Table 1. Complications of genital infections with S. aureus in pregnant women in third

quarter.

Total of patients

(N = 66)

Week 28-32 Week 32-36 Over 36 Weeks

Fever

# / % of patients

3 / 4.55%

7 / 10.61%

5 /7.58%

Leucorrhea

21 / 31.82%

7 / 10.61%

15 / 22.73% # / % of patients

UTI

# / % of patients

8 / 12.12%

12 / 18.18%

6 / 9.09%

UTI = Urinary Tract Infection

7

Table 2. Complications of genital infections with E. coli in pregnant women in third

quarter.

Total patients Week 28-32 Week 32-36 Over 36 Weeks

Fever

# / % of patients

9 / 8,49 %

13 / 12,26%

11 / 10,38%

Leucorrhea

18 / 16,98%

23 / 21,70%

17 / 16,04% # / % of patients

UTI

# / % of patients

9 / 8,49%

17 / 16,04%

11 / 10,38%

UTI = Urinary Tract Infection

Table 3. Complications of genital infections with S. aureus in postpartum women.

Total patients

(N= 87)

Day 1 Day 2 Day 3

Fever

# / % of patients

15 / 17,24% 7 / 8,05% 19 / 21,84%

MAL 9 / 10,34% 16 / 18,39% 11 / 12,64%

# / % of patients

Dysuria

# / % of patients

1 / 1,15% 2 / 2,30% 1 / 1,15%

MAL= modification of appearance of lochia.

Table 4. Complications of genital infections with E. coli in postpartum women.

Total patients

(N=84)

Day 1 Day 2 Day 3

Fever

# / % of patients

9 / 10,71% 4 / 4,76% 13 / 15,48%

MAL 17 / 20,24% 10 / 11,9% 15 / 17,86%

# / % of patients

Dysuria

# / % of patients

14 / 16,67% 8 / 9,52% 19 / 22,62%

MAL= modification of appearance of lochia.

8

Analysis of sensitivity to antibiotics and chemotherapy agents of S. aureus and E. coli

Sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated from pregnant

women with infections (subgroup A1).

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Pen. G

SAM OX CLR CN CLY CXM CRO CIP SXT

Resistant

Sensitive

Figure 2. Graphical representation of sensitivity to antibiotics and chemotherapeutic agents of

S. aureus strains isolated from pregnant women with a history of staphylococcal infections.

The sensitivity of S. aureus strains to penicillin was low, namely: only one single strain

(3.7%) was sensitive to penicillin G, 10 strains (37.03%) to ampicillin-sulbactam and 3 strains (11.11%)

to oxacillin. The sensitivity to macrolides, namely to clarithromycin, was of 48.14% (12

strains), somehow greater than to aminoglycosides-gentamycin 55.55% (15 strains). A low

sensitivity has been recorded to clindamycin – 18.51% (5 strains). A high sensitivity was

obtained to cephalosporins: Cefuroxime sodium 70.37% (18 strains) and Ceftriaxone 66.66%

(18 strains). Yet the highest sensitivity was obtained to ciprofloxacin 74.07% (20 strains). A

significant sensitivity (59.25%) was also obtained to trimethoprim-sulfamethoxazole (16

strains) (Figure 2).

Sensitivity to antibiotics and chemotherapeutic agents of S. aureus isolated from

pregnant women without history of staphylococcal infections (subgroup A2)

On patients of A2 subgroup we found levels of sensitivity to antibiotics of the isolates

strains higher than on patients of A1 subgroup, namely: sensitivity to penicillin G 7.69% (3

strains), to ampicillin-sulbactam 41.02% (16 strains) and to oxacillin 15.38% (6 strains). The

sensitivity to macrolides, namely to clarithromycin, was of 56.41% (2 strains), to

aminoglycosides-gentamicin 61.53% (24 strains). A low sensitivity was recorded to

clindamycin - 23.07% (9 strains).

9

A high sensitivity was obtained to cephalosporins: Cefuroxime sodium 71.79% (28 strains)

and Ceftriaxone 69.23% (27 strains).

Comparing subgroup A1 and subgroup A2, we found that on pregnant women without a

history of diagnosed staphylococcal infections (subgroup A2) the was a significantly higher

sensitivity of S. aureus to the full range of antibacterial agents tested. Therefore, we may suggest

that on carriers of S. aureus, either diagnosed or asymptomatic, the sensitivity to antibiotics of the

germ is reduced compared to non-carriers.

Our observations are consistent with those of other researchers. Asymptomatic

colonization with S. aureus is common; recent studies suggest that about 30% of the U.S.

population carry S. aureus in the anterior nostril and that 1-2% of the population carries MRSA

in the nostrils.7 These people colonized with S. aureus present a higher risk of subsequent

infections than those uncolonized. Most infections are caused by the same strain of S. aureus

that previously colonized the person.8

In response to these findings, greater attention was given to detect S. aureus (especially

MRSA) on carriers, along with their subsequent decolonization as a potential method for

preventing infections with S. aureus. Although the nose is the most common situs in carriers

of S. aureus, the bacteria can also colonize the throat, skin and gastrointestinal tract.9, 10

Sensitivity to antibiotics and chemotherapeutic agents of E. coli isolated from

pregnant women with a history of E.coli infections (subgroup B1) - Figure 3.


pregnant women without a history of E. coli infections (subgroup B2).

In case of the B2 subgroup, the sensitivity to antibiotics of strains of E. coli was as

follows: sensitivity to ampicillin 12.85% (9 strains), to ampicillin-sulbactam 75.71% (53

strains), to gentamicin 78.57% (55 strains), the cefuroxime sodium 74.28% (52 strains), to

cefoperazone 62.85% (44 strains), cefotaxime 54.28% (38 isolates), cefoxitin 64.28% (45

strains) and to imipenem 92.85% (65 strains). The sensitivity to trimethoprim-

sulfamethoxazole was 81.42% (52 strains).

Comparing the sensitivity to antibiotics of subgroups B1 and B2, we found that there is

a marked similarity, which shows that previous infection with E. coli did not increase the

resistance to antibiotics of the bacteria, as observed for S. aureus, regarding bacterial

vaginosis.

Our observations are consistent with data from other studies. The rates of resistance to

antibiotics of E. coli seen in France were significantly smaller than those seen in all the other

countries that participated in the ARESC study, for most of the nine antibiotics studied (the

10

most usually prescribed for cystitis). In France, the prescription of antibiotics, assayed as

daily dose per 1000 inhabitants, is the largest in Europe.11

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Resistant

Sensitive

Figure 3. Graphical representation of sensitivity to antibiotics and chemotherapeutic agents

of E. coli strains isolated from pregnant women with a history of E. coli infections.

This powerful exposure to antibiotics does not appear to affect the rate of resistance to

antibiotics in cystitis. An appropriate use of antibiotics and, especially, a reasoned prescribing

of fluoroquinolones, in accordance with the recommendations, are probably the explanation

for the results of the above mentioned study.12


postpartum women with a history of staphylococcal infections (subgroup C1)

The strains of S. aureus isolated from the patients of this subgroup presented the

following sensitivity to antibiotics: to penicillin G 6.45% (2 strains), to ampicillin-sulbactam

35.48% (11 strains), and to oxacilin 12.9% (4 strains).

The sensitivity to macrolides, namely to clarithromycin, was of 45.16% (14 strains), to

aminoglycosides-gentamicin 51.61% (16 strains). A low sensitivity has been recorded to

clindamycin – 19.15% (6 strains). A high sensitivity was obtained to cephalosporins:

Cefuroxime sodium 67.74% (21 strains) and Ceftriaxone 61.29% (19 strains).

The highest sensitivity was obtained to ciprofloxacine 70.96% (22 strains). A sensitivity

of 54.83% was also obtained to trimethoprim-sulfamethoxazole (27 strains).

11


postpartum women without a history of staphylococcal infections (subgroup C2).

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Pen. G SAM OX CLR CN CLY CXM CRO CIP SXT

Resistant

Sensitive


of S. aureus strains isolated from postpartum women without a history of staphylococcal

infections.

As in the case of pregnant women, we found out that the strains isolated from

symptomatic carriers of S. aureus postpartum women (those who had a history of diagnosed

infections) are significantly more resistant to the antibiotics tested than the strains isolated from

the postpartum women without a history of staphylococcal infections. Comparing C2 subgroup

with A2 subgroup (pregnant women without a history of staphylococcal infections), we found

out a slightly increased sensitivity to antibiotics of strains of S. aureus isolated from postpartum

women, without reaching the significance threshold.


postpartum women with a history of E. coli infections (subgroup D1)

The strains of E. coli isolated from the patients in D subgroup presented the following

sensitivity to ampicillin 8% (4 strains), to ampicillin-sulbactam to 66% (33 strains) to

gentamicin 70% (35 strains), 74% Cefuroxime sodium (37 strains), cefoperazone 56% (28

strains), cefotaxime 46% (23 strains), Cefoxitin 64% (32 strains). To imipenem, the

sensitivity was in 92% (46 strains), to ciprofloxacin 72% (36 strains) and to trimethoprim-

sulfamethoxazole in 74% (37 strains).

Comparing the sensitivity to the antibiotics tested in subgroup D1 (postpartum women

with a history of E. coli infection) to subgroup B1 (pregnant women with a history of E. coli

infection), we found out a higher resistance of the E. coli strains isolated from postpartum

women.

12


postpartum women without a history of E. coli infections (subgroup D2)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Resistant

Sensitive


of E. coli strains isolated from postpartum women without a history of E. coli infections.

In terms of sensitivity to the tested antibiotics of E. coli isolated from patients without

a history of E. coli infection, we found out that there was a slight decrease, not statistically

insignificant, of the sensitivity to antibiotics of strains isolated from postpartum women

compared to those isolated from pregnant women.

Our observations are consistent with data from other studies. The rates of resistance to

antibiotics of E. coli seen in France were significantly smaller than those seen in all the other

countries that participated in the ARESC study, for most of the nine antibiotics studied (the

most usually prescribed for cystitis). In France, the prescription of antibiotics, assayed as daily

dose per 1000 inhabitants, is the largest in Europa.13

This powerful exposure to antibiotics does not appear to affect the rate of resistance to antibiotics in

cystitis. This fact could be explained by the compliance of French doctors who prescribe medicine

with the recommendations of AFSSAPS (the French Agency for the Safety of Health Products).

The appropriate use of antibiotics and, especially, a reasoned prescribing of fluoroquinolones,

in accordance with the recommendations, are probably the explanation for the results of the

above mentioned study.14

The relentless progress of bacterial resistance to drugs compels us to reconsider the

first-intent therapy for some infections.

13

GENERAL CONCLUSIONS

1. Pregnancy is characterized by a state of relative immunosuppression that tolerates

fetal antigens, a necessary condition for fetal survival. There is a high probability that the

pregnant woman is contaminated with germs present in various sources of infection, as well

as the severity of the pathology caused by them.

2. Among the causes of perinatal mortality, the infectious pathology has 20 to 65.6%,

and more than a third of deaths in childbirth and children who died in the early neonatal

period are due to an infectious cause.

3. Bacterial vaginosis is one of the most common vaginal disorders. It results from a

profound imbalance of the vaginal ecosystem, whose mechanisms yet remain unknown,

although recent progress has been made in understanding them.

4. The presence of bacterial vaginosis was found to be a risk factor for adverse

obstetrical outcomes such as preterm labor and preterm birth, premature rupture of

membranes, miscarriage, chorioamnionitis, postpartum infections such as endometritis and

post-caesarean wound infection.

5. In our study, the most common bacterial strains isolated in genital infections in

pregnant and postpartum women were the gram-positive cocci (S. aureus, Streptococcus gr.

B, Enterococcus spp.) and in higher proportion of gram-negative bacilli (E. coli, Citrobacter

spp., Klebsiella spp., Proteus spp., Pseudomonas aeruginosa, Enterobacter spp.)

6. We noticed that the high prevalence of gynecological infections requires that

pregnant and postpartum women be thoroughly investigated. Since the culture provides

identification of the causative pathogens, it must invariably be done.

7. Significant complications seen on pregnant women in the third quarter with genital

infections with S. aureus were represented by leucorrhea (65.15% of cases) and urinary tract

infection (39.39% of cases) and in pregnant women with genital infections with E. coli there

were recorded leucorrhea (54.72% of cases) and urinary tract infection (34.91% of cases).

8. In this study, we noticed a significant correlation between the existence of a

previous infectious episode with the isolated strain and the incidence of genital infection,

both for S. aureus and E. coli.

9. The anatomical and physiological particularities of the pregnant woman’s body ranks

the genital infection among the serious infections. Septic complications significantly increase

in births through caesarean section and therefore administration of antibiotics is necessary

during surgery.

14

10. In order to evade the action of antibiotics, bacteria have the capacity to modulate

the expression of resistance genes, thus ensuring a rapid evolution with a minimum energy

cost, even in the presence of antimicrobial agents. Its resistance manifests at both individual

and population (even global) level, resulting in increased morbidity, mortality, cost/patient

and generally a very large list of problems.

11. In our study, the S. aureus strains isolated from pregnant women who were

colonized in history showed a significantly increased resistance to the tested antibiotics and

chemotherapeutic agents, compared with the strains isolated from pregnant women without a

history of S. aureus infection. Therefore, we may suggest that on carriers of S. aureus, either

diagnosed or asymptomatic, the sensitivity to antibiotics of the germ is reduced compared to non-

carriers.

12. The S. aureus strains isolated from postpartum women with a history of

staphylococcal infections showed a significantly increased resistance to the antibiotics tested,

compared with the strains isolated from postpartum women without a history of

staphylococcal infections.

13. The sensitivity of S. aureus to the antibiotics tested was lower in isolates from

postpartum women compared with isolates from pregnant women, in case of subgroups with a

history of staphylococcal infections.

14. In terms of the high overall level of methicillin-resistance of S. aureus, also

highlighted in our study, the use of oxacillin in first-intention treatment of staphylococcal

infections severe potential becomes inopportune (more than 85% of strains were resistant to

oxacillin). In our study, the highest sensitivity of S. aureus was recorded to

ciprofloxacin, followed by cefuroxime and ceftriaxone.

15. It is noteworthy that, in our study, the resistance of the S. aureus strains to

antibiotics and chemotherapeutic agents tested was significantly increased compared with

E. coli in all cases.

16. The E. coli strains isolated from pregnant and postpartum women showed the

highest sensitivity to Imipenem, followed by Sulfamethoxazole/Trimethoprim and

Ciprofloxacin without significant differences between the groups and subgroups studied.

17. In case of multidrug-resistant strains of S. aureus, sulfamethoxazole/trimethoprim,

whose clinical effectiveness is not fully proven, but recommended by treatment guidelines,

may be a therapeutic option given the high sensitivity when tested in vitro, fact also observed

in the strains analyzed in our study, where 60.17% of all strains studied were susceptible.

15

18. Although clindamycin has increased antistaphylococcal activity, the high

percentage of resistance observed in the tested strains (78.07%) limits the usefulness of

clindamycin in the treatment of genital infections caused by S. aureus.

19. Aminoglycosides must be used in combined therapy, as their use as sole

antimicrobial agent predisposes to emergence of resistance.

20. In order to limit the sometimes devastating consequences of infections with

antibiotic-resistant germs, we emphasize the importance of a closer cooperation in teams

(epidemiologists, microbiologists, clinicians, pharmacists) for the establishment of a way of

monitoring and control of these infections, which are a current and future matter of the health

system.

21. Medical institutions should carry out screening for MRSA on women during

obstetric admission, if they come from communities with a high incidence of MRSA

colonization or if they had hospitalizations in the last 12 months. A culture from the

anterior nostril should be mandatory, as nostrils are the most frequently colonized site.

16

SELECTIVE BIBLIOGRAPHY

1 Gilles R.G. Monif, Infectious Diseases in Obstetrics and Gynecology 5th edition Parthenon, ISBN

1842142097, 2004, 420-425.

2 Shamim Mumtaz, Mumtaz Ahmad, Irum Aftab, Naeem Akhtar, Masood ul Hassan, Abdul Hamid.

Aerobic vaginal pathogens and their sensitivity pattern. J Ayub Med Coll Abbottabad, 2008;20(1):113-

117.

3 Verhelst, R., H. Verstraelen, G. Claeys, G. Verschraegen, L. Van Simaey, C. De Ganck, E. De

Backer, M. Temmerman, and M. Vaneechoutte. 2005. Comparison between Gram stain and culture for

the characterization of vaginal microflora: Definition of a distinct grade that resembles grade I

microflora and revised categorization of grade I microflora. BMC Microbiol. 2005, 5:61.

4 Ghartey JP, Carpenter C, Gialanella P, et al. Association of bactericidal activity of genital tract

secretions with Escherichia coli colonization in pregnancy. Am J Obstet Gynecol 2012;207:297.e1-8.

5 Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Philadelphia:

Mosby Elsevier; 2007, 223-300.

6 Bryan Larsen, Gilles RG Monif. Understanding the Bacterial Flora of the Female Genital Tract.

Oxford Journals, Clin Inf Disease, (2001) Vol 32; 4: e69-e77.

7 Gorwitz RJ, Kruszon-Moran D, McAllister SK, et al. Changes in the prevalence of nasal colonization

with Staphylococcus aureus in the United States, 2001-2004. J Infect Dis 2008;197:1226-34.

8 von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus

aureus bacteremia: study group. N Engl J Med 2001;344:11-6.

9 Ringberg H, Cathrine Petersson A, Walder M, Hugo Johansson PJ. The throat: an important site for

MRSA colonization. Scand J Infect Dis 2006;38:888-93.

10 Nilsson P, Ripa T. Staphylococcus aureus throat colonization is more frequent than colonization in

the anterior nares. J Clin Microbiol 2006;44:3334-9.

11 Elseviers MM, Ferech M, Vander Stichele RH, Goossens H, ESAC project group. Antibiotic use in

ambulatory care in Europe (ESAC data 1997–2002): trends, regional differences and seasonal

fluctuations. Pharmacoepidemiol Drug Saf 2007;16:115–23.

12 Yann Neuzillet, Kurt G. Naber, Giancarlo Schito, Laura Gualco, Henry Botto. French results of the

ARESC Study: Clinical aspects and epidemiology of antimicrobial resistance in female patients with

cystitis. Implications for empiric therapy. Médecine et maladies infectieuses 2012;42:66–75.

13 Elseviers MM, Ferech M, Vander Stichele RH, Goossens H, ESAC project group. Antibiotic use in

ambulatory care in Europe (ESAC data 1997–2002): trends, regional differences and seasonal

fluctuations. Pharmacoepidemiol Drug Saf 2007;16:115–23.

14 Yann Neuzillet, Kurt G. Naber, Giancarlo Schito, Laura Gualco, Henry Botto. French results of the

ARESC Study: Clinical aspects and epidemiology of antimicrobial resistance in female patients with

cystitis. Implications for empiric therapy. Médecine et maladies infectieuses 2012;42:66–75.

Documents

Doctoral thesis -abstract- study of... · Doctoral thesis -abstract-Academic advisor: Professor Dr. FLORICA POPESCU, PhD PhD student: Dr. Camelia Daniela GUTA CRAIOVA 2013. UNIVERSITY